Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events.

BACKGROUND: Perioperative discontinuation of antiplatelet therapy (APT) in patients with coronary stents has been associated with major adverse cardiac events. Our aim was to analyse the perioperative management of APT in such patients and its relationship to the incidence of major adverse cardiac and cerebrovascular events (MACCE) and major bleeding events (MBE) in noncardiac surgery. METHODS: We completed a prospective multicentre observational study of patients with coronary stents undergoing noncardiac surgery in 11 hospitals in Spain. The main objectives were to record perioperative events and prospectively analyse the management of APT, and to assess whether the different preoperative APT regimens were associated with MACCE and MBE. RESULTS: Of 432 surgical procedures studied, 15% experienced a perioperative MACCE and 37% a MBE. Overall mortality was 3.0%. Presurgical APT was prescribed in 95% of procedures, and was preoperatively discontinued in 15%. Surgery was urgent or emergent in 22% of patients, 31% were ASA IV, and 38% had a Revised Cardiac Risk Index of IV. MACCE were related to recent myocardial infarction (P=0.038), chronic kidney disease (P<0.001), insulin-dependent diabetes (P=0.006) and no preoperative APT (P=0.018). MBE also increased MACCE risk (P<0.001). We found statin therapy (P=0.049) and obesity (P=0.016) to be protective factors for MACCE. CONCLUSIONS: Patients with coronary stents undergoing noncardiac surgery suffer a high incidence of perioperative adverse events, even with perioperative APT. Major adverse cardiac and cerebrovascular events are mainly related to previous medical conditions and perioperative major bleeingn events. Our findings should be treated with caution when applied to an elective surgery population. CLINICAL TRIAL REGISTRATION: NCT01171612.

Preoperative estimated glomerular filtration rate and the risk of major adverse cardiovascular and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Chronic kidney disease is an independent predictor of perioperative cardiovascular morbidity and mortality. We analysed the preoperative estimated glomerular filtration rate (eGFR) as a risk factor for perioperative major adverse cardiovascular and cerebrovascular events (MACCE) in non-cardiac surgery. METHODS: In a post hoc analysis of the ANESCARDIOCAT database, patients were classified into six stages of eGFR calculated with the abbreviated Modification of Diet in Renal Disease Study and the Chronic Kidney Disease Epidemiology Collaboration equations: >90 (1), 60-89.9 (2), 45-59.9 (3a), 30-44.9 (3b), 15-29.9 (4), and <15 (5) ml min(-1) 1.73 m(-2). We analysed differences in MACCE, length of hospital stay, and all-cause mortality between eGFR stages. RESULTS: The eGFR was available in 2323 patients. Perioperative MACCE occurred in 4.5% of patients and cardiac-related mortality was 0.5%. Five hundred and forty-three (23.4%) patients had an eGFR of <60 ml min(-1) 1.73 m(-2) and 127 (5.4%) had an eGFR below 45 ml min(-1) 1.73 m(-2). Logistic regression analysis showed that MACCE increased with eGFR impairment (P<0.001), with a marked increase from stage 3b onwards (odds ratio 1.8 vs 3.9 in 3a and 3b, respectively, P=0.047). All-cause mortality was not related to eGFR (P=0.071), but increased substantially between stages 3b and 4. The length of stay correlated with eGFR (P<0.001). CONCLUSIONS: Perioperative MACCE increase with declining eGFR, primarily when <45 ml min(-1) 1.73 m(-2). We recommend the use of preoperative eGFR for cardiovascular risk assessment.

Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery.

BACKGROUND: Major adverse cardiac and cerebrovascular events (MACCE) represent the most common cause of serious perioperative morbidity and mortality. Our aim was to identify risk factors for MACCE in a broad surgical population with intermediate-to-high surgery-specific risk and to build and validate a model to predict the risk of MACCE. METHODS: A prospective, multicentre study of patients undergoing surgical procedures under general or regional anaesthesia in 23 hospitals. The main outcome was the occurrence of at least one perioperative MACCE, defined as any of the following complications from admittance to discharge: cardiac death, cerebrovascular death, non-fatal cardiac arrest, acute myocardial infarction, congestive heart failure, new cardiac arrhythmia, angina, or stroke. The MACCE predictive index was based on ß-coefficients and validated in an external data set. RESULTS: Of 3387 patients recruited, 146 (4.3%) developed at least one MACCE. The regression model identified seven independent risk factors for MACCE: history of coronary artery disease, history of chronic congestive heart failure, chronic kidney disease, history of cerebrovascular disease, preoperative abnormal ECG, intraoperative hypotension, and blood transfusion. The area under the receiver-operating characteristic curve was 75.9% (95% confidence interval, 71.2-80.6%). CONCLUSIONS: The risk score based on seven objective and easily assessed factors can accurately predict MACCE occurrence after non-cardiac surgery in a population at intermediate-to-high surgery-specific risk.